Sterile procedures are required before and during specific patient care activities to maintain an area free from microorganisms and to prevent infection. Performing a surgical hand scrub, applying sterile gloves, and preparing a sterile field are ways to prevent and minimize infection during surgeries or invasive procedures.

Surgical Hand Scrub

Skin is a major source of microorganisms and a major source of contamination in the OR setting (CDC, 2010). Since skin cannot be sterilized, members of the surgical team must wear sterile gloves. The purpose of the surgical hand scrub is to significantly reduce the number of skin bacteria found on the hands and arms of the OR staff (Kennedy, 2013). A surgical hand scrub is an antiseptic surgical scrub or antiseptic hand rub that is performed prior to donning surgical attire (Perry et al., 2014) and lasts two to five minutes, depending on the product used and hospital policy. Studies have shown that skin bacteria rapidly multiply under surgical gloves if hands are not washed with an antimicrobial soap, whereas a surgical hand scrub will inhibit growth of bacteria under gloved hands (Kennedy, 2013).

Types of surgical hand scrubs

Surgical hand scrub techniques and supplies to clean hands will vary among health care agencies. Most protocols will require a microbial soap-and-water, three- to five-minute hand scrub procedure. Some agencies may use an approved waterless hand scrub product. See Checklist 11 for the steps to follow when scrubbing with medicated soap.

Checklist 11: Surgical Hand Scrub with Medicated Soap

Safety considerations:

All personnel entering the operating room (OR) or a specific sterile procedure must perform a surgical hand scrub.

Hands must be free from rings, watches, and bracelets. Nails should be free from any nail enhancements, artificial extenders, acrylics, wraps, and tips. Nail polish must be free from chips or cracks. Research shows that the amount of bacteria is nine times higher on rings and on the skin beneath the fingernails.

All skin on the forearm and hands (including cuticles) should be free from open lesions and breaks in skin integrity. Any allergies to the cleansing products should be reported to the manager.

If hands touch anything during cleaning, the entire procedure must be started from the beginning.

Steps

Additional Information

1. Remove all jewellery.

Jewellery harbours microorganisms.

Remove jewellery

2. No artificial nails, extenders, or chipped nail polish should be worn in the OR.

3. Inspect hands for sores or abrasions; cover or report to supervisor as required.

Open sores can harbour microorganisms.

4. Ensure sleeves are at least two to three inches above the elbows.

This step prevents sleeves from becoming moist.

5. Clean hands with ABHR or soap and water to remove visible debris.

Hand hygiene is recommended by the Association of periOperative Registered Nurses (AORN).

Hand hygiene with ABHR

6. Turn on water.

Regulate the temperature of the water. Warm water is recommended to prevent drying out of hands.

Wet hands

7. Apply the required amount of microbial soap to hands.

A good amount of soap is required to create lather for a three- to five-minute scrub.

8. Keeping hands above elbows, start timing; scrub each side of each finger, between fingers, under each nail with a nail file, and the back and front of hands for the recommended time, according to agency policy.

Nail files work more effectively than a nail brush. Clean the subungal area (under the fingernails) with a nail file. Nail brushes are not recommended as they may damage the skin around the nail.

9. Scrub the arms, using an up-and-down motion, keeping hands above the elbows at all times. Wash each side of the arm from wrist to elbow for one minute.

Keeping hands above the wrist allows for the microorganisms to slide off the hands into the sink.

10. Repeat the entire process with the other hand and forearm.

Use an equal amount of time to wash each hand.

11. With hands raised, rinse hands and arms by passing them through running water, letting the water drip down from the fingertips to the elbow.

This step allows for all the soap to be rinsed off from cleanest to dirtiest area.

12. Proceed into the operating room (keep hands above the waist), and dry arms using a sterile towel, starting at the fingertips and working down toward the forearms using a dabbing motion.

This step prevents contamination of the hands and adheres to the principles of sterile technique.

Watch a video or demonstration to learn how to perform hand hygiene using the traditional hand scrub method.

Watch a video or demonstration to learn how to perform surgical hand scrub using an alcohol-based hand rub method.

Applying Sterile Gloves

Sterile gloves are gloves that are free from all microorganisms. They are required for any invasive procedure and when contact with any sterile site, tissue, or body cavity is expected (PIDAC, 2012). Sterile gloves help prevent surgical site infections and reduce the risk of exposure to blood and body fluid pathogens for the health care worker. Studies have shown that 18% to 35% of all sterile gloves have tiny holes after surgery, and up to 80% of the tiny puncture sites go unnoticed by the surgeon (Kennedy, 2013). Double gloving is known to reduce the risk of exposure and has become common practice, but does not reduce the risk of cross-contamination after surgery (Kennedy, 2013).

3. Inspect hands for sores and abrasions. Cover or report to supervisor as required.

Open sores can harbour microorganisms.

4. Ensure sleeves are at least two to three inches above the elbows.

This step prevents sleeves from becoming moist, and prevents the transfer of microorganisms from the sleeves.

5. Clean hands with ABHR or soap and water.

This step decreases the bacterial count on hands and prevents contamination of sterile equipment.

Hand hygiene with ABHR

6. Clean surface to open sterile field and raise its height to waist level.

All sterile items must be kept above waist level.

7. Inspect packaging for sterility.

All sterile items must be checked for sterility prior to use. Always examine sterile glove packaging for expiry date, intactness, and tears. The package should be dry. Sterile gloves have outer packaging that must be removed prior to starting the procedure of applying sterile gloves.

Inspect outer packaging

8. Open sterile packaging by peeling open the top seam and pulling down.

Open sterile packaging without contaminating inner package.

Open sterile glove packaging

9. Place inner package on working surface and open up to see right and left gloves. Start with dominant hand first. Open packaging.

Setting up a Sterile Field

Aseptic procedures require a sterile area in which to work with sterile objects. A sterile field is a sterile surface on which to place sterile equipment that is considered free from microorganisms (Perry et al., 2014). A sterile field is required for all invasive procedures to prevent the transfer of microorganisms and reduce the potential for surgical site infections. Sterile fields can be created in the OR using drapes, or at the bedside using a prepackaged set of supplies for a sterile procedure or wound care. Many sterile kits contain a waterproof inner drape that can be set up as part of the sterile field. Sterile items can be linen wrapped or paper wrapped, depending on whether they are single- or multi-use. Always check hospital policy and doctor orders if a sterile field is required for a procedure. See Checklist 13 for the steps for preparing a sterile field.

Sterile Attire in the OR

Wearing sterile surgical attire (sterile gowns, closed gloving, and masks) and PPE is essential to keep the restricted and semi-restricted areas clean and to minimize sources of microbial transmission and contamination. It is important to minimize the patient’s exposure to the surgical team’s skin, mucous membranes, and hair by the proper application of surgical attire. An extensive list of recommendations for surgical attire can be located on the Association of periOperative Registered Nurses (AORN) website at Recommendations for surgical attire (Braswell & Spruce, 2012).

Watch a video or demonstration to learn how to don surgical attire.

Watch a video or demonstration to learn how to apply a sterile gown independently.

Watch a video or demonstration to learn how to apply sterile gloves using the closed gloving method.

Watch a video or demonstration to learn how to apply sterile gloves using the assisted gloving technique.

Critical Thinking Exercises

Name four differences between a medical hand wash with soap and water and a surgical hand scrub.

When preparing a sterile field, is the first flap open toward the health care provider or away from the health care provider?

Name two reasons for performing hand hygiene before and after applying sterile gloves.

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